NYC Medicaid Fraud Basics

New York Medicaid Fraud Cases

NY Medicaid fraud investigation begins when Medicaid fraud investigator obtains information that suggests that a person is receiving Medicaid benefits illegally. This information may indicate a person is not qualified for the Medicaid benefits they are receiving or worse. Many times this information is obtained from a variety of records. This includes property records, business records, payroll records and more. A Medicaid fraud investigator may even obtain information about a person from their co-workers or even people living in their neighborhood.

Notification
A person will usually learn they are the subject of a Medicaid fraud investigation after receiving a letter from an investigator. The letter will usually ask the person to produce a number of documents. The investigator will then want to meet with the person for an interview.

Accusations
There are a number of reasons a person may be investigated for Medicaid fraud. The investigator could suspect a person did not tell the truth on their application. This could include information about their income, assets and more. Some people are suspected of reselling the medicine or other products they received through the Medicaid program. Others are accused of forging, altering or receiving duplicated prescriptions. Others may have obtained services they are not eligible to receive. In some cases, people are accused of letting another person use their Medicaid card. There are individuals who are accused of having and using more than one Medicaid card.

Meeting
It’s important that people realize when they get this letter, the investigator has already collected evidence against them. The Medicaid fraud investigator believes the person has broken the law. Anything a person says during their meeting can be used against them in the future. An innocent mistake could result in a person having criminal charges filed against them. People have a right to have an attorney with them during this meeting. An experienced Medicaid fraud attorney should be consulted before anything is said to the Medicaid investigator, or any documents are provided.

Rights
A person has the right to have an attorney present when they meet or speak with the Medicaid fraud investigator. An individual does not have to answer the investigators questions. It is within their rights to say nothing. A person who is being investigated and receives benefits from the Family Health Plus or Medicaid won’t have their benefits canceled simply because they refuse to answer an investigators questions. How a person is advised to approach the situation will depend on the facts of their individual case. An appropriate question, as well as document request, will be addressed. The investigator could also ask questions and have document requests that are improper. In some situations, the best way to handle the situation is to cooperate with the investigator. An experienced attorney will know how to negotiate the best possible result. The goal will always be to protect an individuals rights.

Possible Penalties and Punishments for Medicaid Fraud
When a person is guilty of Medicaid fraud, there are a variety of punishments they could receive. A person may have to repay Medicaid for the benefits they received and in some cases, individuals will go to prison. People have also been excluded and disqualified from receiving any Medicaid benefits in the future. Some people have even received civil judgments as well as liens on any real property they own. It’s possible a person’s wages could be garnished or their professional license suspended or terminated. Depending on a person’s immigration status, they could even be deported.

Administrative Disqualification Hearing
In some situations, the government may believe a person has intentionally defrauded Medicaid, but their fraud does not rise to the level of criminal prosecution. The reason for this is the amount of fraud is too small. The case may then be referred to the Office of Administrative Hearings (OAH). This is part of the New York State Department of Social Services (NYSDSS). This is where an administrative disqualification hearing will take place. The purpose of the hearing is to decide if a person intentionally defrauded Medicaid and if they should be disqualified from getting benefits for a period of time or never again.

Hire NYC Medicaid Fraud Attorney
An experienced lawyer will know what needs to be done in a Medicaid fraud allegation case. If a case can’t be defended in court, a knowledgeable attorney will know how to reduce a person’s criminal exposure. A lawyer will know how to assemble all of the important information to get their client the best possible outcome. They will know how to work with a specific judge or prosecutor. Most individuals who are prosecuted with Medicaid fraud in a New York court are charged with a felony. A guilty plea will result in a person having a criminal record. An attorney will know how to negotiate with a DA or Judge to have their client plead to a reduced Misdemeanor charge. In some situations, they can also negotiate a plea bargain. This will enable a person to avoid a criminal conviction, as well as a criminal record.

Medicare vs Medicaid

Medicare is a program that authorized federal financing of healthcare costs for the elderly. Under the Medicare program, the government reimburses the claims submitted by health care providers who are paid by private insurance companies, which are in turn reimbursed out of the Federal trust funds.

Medicaid, on the other hand, is financing program those with low-income. In New York, Medicaid is administered by the Department of Health through local social services agencies.

Any frauds committed against Medicaid or Medicare may be prosecuted under numerous federal criminal statutes, including conspiracy, insurance fraud, healthcare fraud, mail and wire fraud, etc.

Both beneficiaries and providers can be prosecuted for Medicaid and Medicare fraud in federal courts, although for practical purposes, beneficiaries who commit this type of fraud (generally by lying on their applications about their income and resources) are rarely prosecuted in federal courts in New York. In other states, federal prosecutors are more likely to make it a federal case out of this situation, while in New York practically all cases involving recipient fraud are prosecuted in state courts.

Healthcare providers are in a different position and are more likely to be prosecuted in federal courts for Medicaid and Medicare fraud.

There is a variety of reasons that can trigger a federal criminal prosecution of such case, including making material false statements, submitting false claims, or being involved in a kickback scheme.

New York is also one of the state that have established the Medicaid Fraud Control Unit responsible for investigating and prosecuting Medicaid fraud cases under the umbrella of the state Attorney General’s Office.

Successful defense of New York Medicare and Medicaid cases require a defense lawyer who understands how the reimbursement process works. Medicare reimbursement is a complicated system that uses various methods to pay various providers based on many factors.

Our clients are both Medicaid Recipients as well as Medicaid Providers, such as doctors, dentists, clinics, nursing home managers, pharmacists, home care providers, and ambullette transportation business owners who have been accused of administrative or criminal fraud violations of any of Medicaid eligibility rules.

Medicaid Fraud Settlements

Medicaid fraud is an occurrence of which many providers and recipients are accused. Medicaid fraud includes a wide variety of actions and omissions of actions that result in a person receiving benefits to which he or she is not entitled. Medicaid fraud can include a medical facility receiving payment for services to which it is not entitled, as well. The government is starting to crack down on its investigative efforts and its prosecutions. Yearly Medicaid fraud incidents add up to billions of dollars. Persons who are found guilty of such fraud can face a wide variety of harsh penalties.

Examples of Medicaid Fraud
As previously stated, a wide variety of situations may be considered as Medicaid fraud. First a recipient has to meet income guidelines to qualify for Medicaid. The person must have income that is below the poverty level. An applicant can manipulate his or her income as to qualify for Medicaid. Such manipulation is Medicaid fraud. Another example of Medicaid fraud is when a person does not report insurance that he or she already has. Some Medicaid applicants may have employer-issued coverage or some other coverage that they fail to report. Gaining approval for Medicaid benefits without reporting existing benefits is Medicaid fraud.

A person who has Medicaid benefits cannot allow another person to use his or her benefits. The state approves Medicaid benefits only for the person who applies for it. Therefore, Medicaid fraud occurs when someone else uses the card.

Providers can be just as guilty of Medicaid fraud as recipients are. One fraudulent act that a provider may conduct is billing the Medicaid office for services that it has not rendered to a patient. The provider may bill the Medicaid office for services that the patient did not need, as well. An example is a provider that bills Medicaid for administration of a nebulizer treatment that the patient did not need. The government provides an easy way for people to report instances of Medicaid fraud. Therefore, an accused party may be under investigation shortly after someone places an anonymous tip with a government organization. The penalties for Medicaid fraud are extensive, and anyone who receives a charge would fare well by hiring an attorney who can come up with a viable defense to the charge.

Punishment for Medicaid Fraud
The penalty for Medicaid fraud can vary depending on the offender’s circumstances. The investigation will include a series of questions as the issuing organization tries to find out whether the accused person was intentionally fraudulent. Next, the investigator will review medical documents, bills, income information and any other information that is relevant to the case. The punishment for fraud will most definitely include temporary or permanent suspension of benefits for an individual who commits the crime.

Medicaid fraud is severe because it is a federal crime. A person who is accused of fraud can be subject to criminal and civil charges. A criminal conviction can land a person in prison for as long as five years with a fine of up to $200,000. A corporation that is found guilty of Medicaid fraud may be subject to a $500,000 fine. The civil penalty for such a crime may include an additional fine of up to $10,000. The consequences of Medicaid fraud can be long-lasting for anyone who receives a conviction. The guilty party will have difficulty receiving assistance from the government in the future. A person will have difficulty getting hired for a job in the future, as well. A corporation may lose business and investors.

Medicaid Fraud Settlement
Medicaid fraud settlement is a situation in which a corporation or a person settles out of court on a Medicaid fraud charge. Medicaid fraud settlements usually occur when someone accuses a corporation of Medicaid fraud. The corporation may be allowed to pay a set fine to keep the proceedings from going to levels that would put the corporation out of business. Additionally, the offending corporation may be instructed to allow a third party to monitor its operations during a probationary period. A deferred prosecution agreement is one that allows an accused party to enter a settlement to defer harsh penalties.

NYC Medicaid fraud lawyers with Joseph Potashnik & Associates have handled the most Medicaid fraud investigations in New York. Call us today to set up your confidential consultation.

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